Thank You for Saving My Life!

By Dr. Cheryl BryantBruce, M.D.

I stood at the door watching the ambulance roll slowly out of the bay. As I shot a parting
glance over my shoulder, Donna (not her real name) wanly opened her eyes and waved. I
could detect just a hint of a peaceful smile.

My day with Donna had started at 0645 am. I had just laid down to go to sleep, when I
was called to the ER. Donna had not arrived yet, but I was told that she was en route and
that I would know her when she arrived because she was a little “off kilter.” “Great.” I
thought to myself, shaking my head. Nothing coming in this week had been
straightforward or easy. I kicked myself for not having gone to bed earlier.

When I arrived in the ER, Donna was propped up on a gurney looking very sleepy. As I
questioned her, she barely opened her eyes and slurred her words. Asking her to repeat
things wasn’t helping at all. Finally, I had to sternly instruct her to sit up, in order to get
her alert enough to reasonably answer my questions. In her almost obtunded state, this
cherubic faced woman, with her mousy brown hair that was pulled austerely back from
her face seemed a far cry from the raving, hysterical woman that the receptionist had
described some 15 minutes beforehand. The woman was decidedly a picture in contrasts.
My conversation with Donna felt somewhat schizophrenic. I found myself feeling a good
bit irritated with her and reflected back on my medical school days, when we had been
instructed that patients with borderline personality disorders often incited such intense
feelings in medical staff. She waxed and waned between being completely lethargic and
being overly bright and chatty.

I listened warily as Donna gave a somewhat convoluted story of having had a simple
knee surgery three weeks before at our orthopedic hospital, after which she did quite
well. Following her discharge, she developed complications. A deep aching in her left
leg began eight days prior to admission. Donna spent five days in another hospital being
treated for a blood clot in her left leg. She was discharged home pain free. The ER nurse
had told me that Donna reported having developed pain again one day before coming. As
I questioned her further, Donna informed me that she had been to another emergency
room and had a Doppler ultrasound that revealed that although she was on a therapeutic
dose of Coumadin, the clot in her leg had expanded substantially. She reported she had
then been discharged and allowed to drive home.

As Donna told her story, I noted that her level of consciousness had been waxing and
waning. I began to wonder what drugs she might be on. She had a family history of
mental illness and had attempted suicide just two months previously. When I asked her,
she listed 13 different medications and 15 medication allergies. Intermittently she would
complain loudly about her pain. I found myself reluctant to give her any pain meds, since
it appeared she was already drugged. She then explained that she had taken some pain
medication to help her drive to our hospital.

© 2009, Dr. Cheryl BryantBruce, M.D. All rights reserved. You must have the express
written consent of author to reproduce any part of this document for other than personal
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Donna explained that she had awakened with intensifying pain in her left leg and had
called her cardiologist. Although she reported to him that she had shortness of breath and
pain in her chest, he assured her that it was not her heart. He told her that he didn’t need
to see her, because she was a surgical patient and it wasn’t her heart and was more likely
due to a post-surgical complication than due to the venous clot. He recommended that
she drive the two hours north to come see the surgeon.

I casually observed Donna, as she told her story, a different story than the one that she
had given Caroline, my perky and extremely competent nurse. At first I doubted its’
veracity. I found it hard to believe that she had been discharged from another hospital
with an expanding DVT on a therapeutic Coumadin dose. I wondered why they would
not have admitted her to get an umbrella cage filter placed in her veins to keep her from
throwing clots into her chest or to her brain. I tasked Caroline to order the records to
confirm her outlandish and ever changing story. At the same time I ordered a drug
screen, worried this woman might be one of the many, manipulative drug seekers.
Although she had recently had an arthroscopic surgery and her knee was tender, the
majority of her pain was in her left calf and the back of her thigh, but seemed out of
proportion with what I was clinically seeing, even if she did really end up having the
DVT. Her knee was not swollen or red. She desperately pointed out an almost non-
existent hint of blackish discoloration from her left thigh to her ankle. She rapidly
flipped between being drowsy from very tiny amounts of pain medication and being
chatty and then complaining hysterically about her pain. I found myself wondering how
much of this was in her head. She seemed quite odd, but I reminded myself that
psychiatric patients get sick too.

As I continued to observe Donna, a scenario was forming in my head. I could see how
the personality of this woman with the wheedling voice and the almost childlike behavior
might have irritated the staff at the former ER. Quickly identifying her psych history,
they hadn’t taken her very seriously. Even in light of a serious finding like an expanding
DVT, I could see how the clinical judgment of a tired physician in a busy ER could have
become clouded by a visceral reaction to her seemingly manipulative personality. He had
perhaps thought she was a drug seeker. I began to imagine that she had conjured up these
same feelings in her cardiologist. Perhaps she had cried wolf a few too many times. I
was grateful for the opportunity to work in a specialty hospital that afforded me the
advantage of having the time to sort out the pieces.

I broke out of my musing to see Donna’s eyes now wide open and fixed on my face, as
she chattered frantically and then moaned loudly. Our eyes locked briefly. Her round
face appeared much younger than her stated age. She had that deer in the headlights look
for a brief moment. I brushed a brown wisp of hair gently from her face. A churning
feeling deep in my gut was telling me that something wasn’t quite right. I asked Caroline
to get a full set of labs, to order a repeat of the Doppler US to verify her story and to have
a comparison when we obtained her old records. Caroline informed me that the surgeon
was concerned about a fluid collection that might have to be drained in Donna’s knee, so
I added an MRI of the knee to see what derangement might be there.

© 2009, Dr. Cheryl BryantBruce, M.D. All rights reserved. You must have the express
written consent of author to reproduce any part of this document for other than personal
utilization.
Caroline’s blond hair bobbed jauntily down the hall as she scurried off to carry out my
orders. I completed the remainder of my exam, noting specifically that Donna’s lungs
sounded clear. When Caroline returned, I asked her to listen to Donna’s lungs. She
independently confirmed that they sounded clear. I stared at Donna intensely, asking her
for yet a third time if she had any shortness of breath or chest pain. This time, after some
hesitation, she stated that she had these symptoms, but couldn’t remember if it was last
night or the night before. I threw a glance at Caroline. A slight smile turned the corner
of her lip. She knew that my inner self was shaking her head in exasperation, but on the
outside, I patted Donna’s hand reassuringly, then I wrote for the order for a CT scan of
her chest with contrast dye to rule out a blood clot in her lungs.

Reports from the other ER arrived minutes before the ultrasound technologist arrived.
Much to our surprise, they confirmed Donna’s story of an expanding clot. The labs
showed that she had a high therapeutic value of the Coumadin that was supposed to be
dissolving the clot. Donna was in the meantime rolling out a laundry list of prior medical
problems, along with a plethora of social ones. She lamented that her kids weren’t
speaking to her. She complained loudly of the pain. I wondered where my drug screen
results were. I instructed my nurse to give her a small amount of pain medicine to see
how she would respond and something for her anxiety. She soon was comfortable, but
then became lethargic again. I picked absently at a bump on my face. Caroline slapped
my hand. I looked at her vitals again…stable blood pressure, no rapid heart rate…no
rapid breathing. Her oxygen saturation was a bit low though. I raised an eyebrow
quizzically. It was unlikely to be a PE with such stable vitals and clear lungs, but she still
wasn’t oxygenating her blood as well she could. I put her on some oxygen. She did have
risk factors. She recently had surgery, she was obese and hadn’t moved around much,
and she was not compliant with taking her medications properly.

The test results began coming in. Our repeat of the ultrasound confirmed the results of
the previous day. The clot in Donna’s left leg was extensive, but had not changed much
from the day before. We only looked up to her thighs, but the radiologist concurred with
my suspicion that the clot was probably well up into her pelvis. The MRI of the knee
showed a collection of fluid behind her knee cap and in the muscle at the front of her
thigh. More importantly, it also confirmed the extensive clotting of almost all of the
veins of her left leg. Finally the results of the CT angiogram came in. I felt tightness in
my throat, as Dr. Moore, stated emphatically that Donna was a time-bomb and that we
needed to get her transported quickly to a higher level facility. Out of all of our
radiologists, I had the most confidence in the readings of the tall and handsome Dr.
Moore. He was always pleasant, very knowledgeable and always willing to teach. Today
his brow was knitted though and his voice terse.

I went back to Donna’s room, where she was now leaned back, wide awake and
seemingly enjoying immensely all of the attention she was receiving. Caroline stood
patiently by her side seeming to hang on her every word. “The woman is a saint, “I
thought to myself. Donna chattered on about how much she liked it at our facility and
how none of the other doctors seemed to have time to listen to what she was trying to tell
them. She even reported that she had been to her hometown ER and complained of chest
© 2009, Dr. Cheryl BryantBruce, M.D. All rights reserved. You must have the express
written consent of author to reproduce any part of this document for other than personal
utilization.
pain and shortness of breath prior to her surgery. She said that she had just been “brushed
off.” Her face reflected that she was sorely vexed about this. She was tender-hearted and
it was clear they had hurt her feelings and made her feel insignificant. I understood how
and why they had arrived at that point, but I felt the heat rise in my neck, as I thought
about her driving to our ER by herself, heavily medicated and in pain, with a clot steadily
expanding in her leg.

I stepped to the side of Donna’s bed, putting my hand lightly on hers. She drew toward
the touch, seeking the comfort hungrily. I looked her straight in the eyes. “Donna, “I
said solidly, “I have good news and I have bad news. The good news is that we have
results. The bad news is that they are not good.” I explained to her that along with the
clot in her leg, almost every vessel in her chest had clot in it.

Donna stared at me vacantly for a moment. Then, she asked in a small, but steady voice,
“Am I going to die?”

“Not on my watch!” I squeezed Donna’s hand firmly. “Donna, what you have going on
is very serious, We’re going to do everything that we can to see that you do well, but you
are at high risk for a stroke , and honestly, there is a possibility that you could die from
this.”

Glassy pools welled up in Donna’s eyes. Then, I felt like banging my head against the
wall, as she uttered, “I think I need to go out and smoke a cigarette.”

I glared at her. “You will not,” I stated flatly.

I felt my stomach tighten and choked back a laugh, as she looked at me with a poker face,
petulantly saying, “I don’t inhale.”

Again, I gave Donna’s hand a squeeze. “I can’t promise you anything, but that I will do
my best for you Donna. Right now that means that I have to transfer you somewhere else
where you can get the higher level of care you need in a place that specializes in the type
of care that you need.”

Donna looked away for a moment, seeming to intensely study a non-captivating poster
that we had displayed on the wall beside her. Then she looked back at me. Her eyes said
so many things. Her mouth said, “You listened….thank you for saving my life.”

As the ambulance rolled out of sight, I again saw her mouth the words, “Thank you for
saving my life.”

Caroline and I stood silently looking in the direction the ambulance had taken. The air
was warm and humid. Caroline nudged me with her shoulder. I nudged her back. We
turned and walked back into the ER. It had been a good day!

© 2009, Dr. Cheryl BryantBruce, M.D. All rights reserved. You must have the express
written consent of author to reproduce any part of this document for other than personal
utilization.
.
Speculating on the healthcare debates that are raging right now, do you feel like you get
to spend too little, too much or just the right amount of time with your doctor and why do
you feel that way?

© 2009, Dr. Cheryl BryantBruce, M.D. All rights reserved. You must have the express
written consent of author to reproduce any part of this document for other than personal
utilization.